The association between health information attitudes and skills in patients with chronic disease in China

Abstract

Objectives:

To assess and explore the relationship between the health information (HI)-related attitudes and skills of patients with chronic disease in China.

Methods:

A questionnaire was developed to measure the participants’ HI-related attitudes and skills. The study included all participants (N = 1671) undergoing routine physical examinations at the Health Management Centre, Third Xiangya Hospital of Central South University, Changsha, Hunan province, from September to November 2013. The Kruskal–Wallis test was used to assess the impacts of social demographic factors and chronic disease conditions on the patients’ HI-related attitudes and skills. Multiple linear regression and bivariate correlation analyses were adopted to explain the relationship between attitudes and skills.

Results:

The chronic disease patients clearly know that HI was valuable for their health, but their general HI-related skills were inadequate, particularly for elderly and undereducated patients. Additionally, the participants’ HI attitudes positively correlated with their HI-related skills (r = 0.47, p < 0.001). Because the attitudes ascended by grade (i.e. negative, moderate, and active), the HI-related evaluation, expression and comprehension, and seeking skills categories increased by 11%, 5.3%, and 8.4%, respectively.

Conclusions:

Although the chronic disease patients held explicit and active attitudes towards HI, their skills were unsatisfactory. Attitudes and skills, however, present a positive relationship. These results suggest that training in HI-related skills should be the main goal of health literacy promotion in patients who suffer from long-term chronic diseases, particularly elderly and undereducated patients. However, cultivating an active attitude towards HI is important to improve HI-related skills.

Keywords

chronic disease health education health information literacy

Introduction

With the accelerated pace of global informatization, the ability of the public to quickly acquire health information (HI) has become necessary in developed and developing countries. Individual HI literacy directly influences patient health (1). As in many developing countries, chronic diseases such as cardio-cerebrovascular disease, cancer, diabetes, and chronic respiratory disease have become a significant burden in China, as well as the leading cause of mortality by far, representing 70% of the total health burden and 85% of all deaths (2). Thus, improving the HI literacy of chronic disease patients is imperative to reduce health risks and premature death or disability and to relieve the social burden (3).

The concept of HI literacy originated from an in-depth study of health literacy. In 1974, Simonds first used the term ‘health literacy’ in his paper ‘Health education as social policy’ (4). As shown by a series of studies in (approximately) the year 2000, public health literacy education has had many problems, such as poor readability of HI, weak reliability of HI sources, and the public’s inability to assess HI, that have greatly reduced the effects and efficiency of public health literacy promotion (5,6). In 2003, combining the concepts of information literacy and health literacy, the Medical Library Association (MLA) for the first time promoted the concept of HI literacy and emphasized the important role of acquiring HI skills in individual health literacy (7). For the past ten years, studies have shown that individual HI skills are essential for improving individual health and reducing medical costs (8 –11).

After diagnosis, patients with chronic diseases generally must cope with their illnesses for the rest of their lives. Therefore, it is important to obtain good HI skills for health promotion and disease rehabilitation. Kent et al. investigated HI needs and their association with health-related quality of life in a population of long-term cancer survivors and found a diverse array of HI needs (12). Meesters et al. found that many rheumatoid arthritis patients had little knowledge or information about the contents and accessibility of regional health care services (13). Keogh et al. searched for carotid endarterectomy-related information using Google^TM search and reported that websites that provided information on carotid disease management must be more readable, reliable, and usable (14). Other studies have been conducted to investigate the application of online HI by minority chronic disease populations in Los Angeles (15), the mastery and inquiry of blood transfusion information by chronic renal disease sufferers (16), and the identification of and need for HI by Australian aborigines suffering from chronic cardiac failure (17).

Most of the previous studies have focused on a specific disease-related issue (e.g. cancer, rheumatoid arthritis, congestive heart failure, etc.). In the present study, we assessed the HI-related skills and attitudes of patients with chronic disease, and we explored the relationship between the skills and attitudes.

Methods

Study design

This study is part of the Health Information Literacy Investigation and Improvement Plan of Residents in Hunan Province. From September to November 2013, 12,762 physical examination participants at the Third Xiangya Hospital of Central South University were surveyed. An investigator briefly explained the aim of the study. After the participants consented to participate in the study, they completed a questionnaire. If the participants had difficulty understanding the questionnaire, the investigator provided assistance. Each questionnaire, which required approximately 10 min to complete, was retrieved upon completion.

The following inclusion criteria were applied: (i) at least 15 years of age; (ii) diagnosed with at least one chronic disease; and (iii) mentally and physically able to participate. The exclusion criteria were (i) being unwilling to participate in the survey and (ii) missing questionnaire responses.

A total of 2096 questionnaires were returned, among which 1761 valid questionnaires were obtained. In this study, chronic disease was defined according to the chronic disease types described in the Working Plan for the Prevention and Treatment of Chronic Diseases (2012–2015) by the National Health and Family Planning Commission of the People’s Republic of China (18). The chronic diseases included cardiovascular/cerebrovascular diseases, diabetes mellitus, cancer, asthma/chronic obstructive pulmonary diseases (COPD), neurological diseases, digestive system diseases, and others.

Instruments

A survey instrument was developed to measure the participants’ attitudes towards health-related information (measured by nine items, see Table 2) and HI skills (measured by 12 items, see Table 3). Exploratory factor analysis was performed to test structure validity, and reliability analysis was performed to test reliability. For the ‘attitude towards HI’ scale, exploratory factor analysis (KMO = 0.724, approx. chi-squared = 4973.269, p < 0.001) showed that the factor loading of the nine items ranged from 0.452 to 0.683, thereby confirming the scale structure. The internal reliability (Cronbach’s α) of the 9 items was 0.701. For the ‘HI skills’ scale, exploratory factor analysis (KMO = 0.777, approx. chi-squared = 5636.802, p < 0.001) indicated that three principal components were evaluation ability (Item 1–Item 3), expression and comprehension ability (Item 4–Item 8), and seeking ability (Item 9–Item 12). The factor loading of the 12 items ranged from 0.453 to 0.731, and the internal reliability (Cronbach’s α) of the scale and its three components were 0.756, 0.717, 0.756, and 0.789, respectively. The Pearson correlations of the three factors (p < 0.01) ranged from 0.151 to 0.266. All items on the two scales were answered on a five-point scale (1 – completely agree, 0.75 – agree, 0.5 – don’t know, 0.25 – disagree, 0 – completely disagree).

Finally, seven single-choice questions (trustworthy/general/ untrustworthy) were designed to evaluate participants’ confidence concerning the reliability of seven familiar HI sources.

Data analysis

Analysis was conducted using the Statistical Package for Social Sciences Version 17.0 (SPSS Inc., Chicago, IL, USA). The scores of the two scales were obtained by summing the relevant item scores, such that a higher score indicated a stronger attitude or more HI. Group differences in the scores were examined using Kruskal–Wallis (KW) tests and mean scores were determined by t-tests. Multiple linear regression analysis was conducted to explore whether the demographic and disease characteristics of the patients with chronic diseases were related to their HI-related attitudes and skills.

The relationship between the attitudes towards HI and HI skills was examined in two manners. First, to determine whether attitudes predicted the patients’ skills, attitude was added to the four linear regression analyses as a dependent variable. Conversely, to explore whether HI skill level predicted the patients’ attitudes towards HI, three skill-related factors were added to the attitude linear regression model as dependent variables. Second, according to score, attitudes towards HI were divided into three groups, and the correlations between the attitudes and the three skill factors were analyzed on three levels. To conveniently describe the frequency distributions of HI-related attitudes and skills, all items on both scales were classified into three categories: ‘disagree’ (combining ‘completely disagree’ and ‘disagree’), ‘agree’ (combining ‘completely agree’ and ‘agree’), and ‘don’t know.’

Ethical approval

Ethical approval for the study was obtained from the Medical Ethics Committee of the Third Xiangya Hospital of Central South University, and the surveys were completed anonymously.

Results

Demographic characteristics

Demographic and illness information for the study participants is listed in Table 1. Of the 1671 participants, the majority were male (58.2%). The majority of participants (51.6%) were 41–60 years of age, and the mean age was 43.8 years (standard deviation (SD) = 10.71). Education was classified as basic (never attended school, elementary school, middle school, high school), intermediate (primary or intermediate vocational education), or high (bachelor’s, master’s, or doctoral degree). The major chronic diseases were cardiovascular/cerebrovascular disease, asthma/COPD, and diabetes mellitus, which accounted for 63.3% of the total number of participants. The percentage of patients suffering from at least two chronic diseases was 5.4%. The average post-diagnosis time was 7.9 years (SD = 5.7).

Table 1.

Demographic data and illness characteristics of the study participants (N = 1671).

	Number	Percent
Gender
Male	973	58.2
Female	698	41.8
Age
15–40	692	41.4
41–60	862	51.6
61 and older	117	7
Education level
Basic	188	11.3
Intermediate	1311	78.5
High	172	10.3
Annual household income (in CNY)
<40,000	276	16.5
40,000–100,000	887	53.1
100,001–200,000	390	23.3
≥200,001	118	7.1
Religious beliefs
Yes	95	5.7
No	1576	94.3
Disease category
Cardiovascular/cerebrovascular disease	472	28.2
Diabetes mellitus	287	17.2
Cancer	95	5.7
Asthma/COPD	296	17.7
Neurological disease	132	7.9
Digestive system disease	138	8.3
Other chronic disease	251	15
Number of chronic diseases
One disease	1581	94.6
Two	71	4.2
Three or more	19	1.2
Time post-diagnosis
≤5 years	748	44.7
5–10 years	429	25.7
≥10 years	494	29.6

Attitudes towards HI

The results of the chronic disease patients’ attitudes towards HI are shown in Table 2. Most patients agreed that health-related information was helpful for disease prevention (97.3%) and treatment (94.0%). Similar results were observed for Item 4–Item 8, which indicates that patients with chronic illnesses clearly know that HI is valuable for their health.

Table 2.

Attitudes towards health information^a.

	Agree n (%)	Uncertain n (%)	Disagree n (%)
1. I think health information is helpful for disease prevention.	1625 (97.2%)	40 (2.4%)	6 (0.4%)
2. I think health information is helpful for treating diseases.	1571(94.0%)	89 (5.3%)	11 (0.7%)
3. I am willing to study new methods or skills to search for health information.	668 (40.0%)	462 (27.6%)	541 (32.4%)
4. I am willing to take the initiative to find needed health information.	1468 (87.8%)	182 (10.9%)	21 (1.3%)
5. I will notice and remember the health information that may be helpful to me and my family members.	1570 (93.9%)	81 (4.8%)	20 (1.3%)
6. I think health information quality is very important.	1468 (87.8%)	158 (9.4%)	45 (2.8%)
7. I am willing to apply health information to my relatives.	1204 (72.0%)	226 (13.5%)	241 (14.5%)
8. I am willing to apply the health information to myself.	1536 (91.9%)	108 (6.5%)	27 (1.6%)
9. I am willing to take the initiative to share health information with people around me.	153 (9.2%)	347 (20.8%)	1171 (70.1%)

Nine items, Cronbach’s α = 0.701.

The results showed that the respondents’ answers regarding their willingness to study new HI research methods or skills were relatively even among the three options. The KW test indicated that females (t = 4.40, p < 0.001) and older patients (χ² = 14.13, p = 0.001) were more confident than males and younger patients. Moreover, the more highly educated patients were more willing to study new HI research methods or skills compared with the patients who had only elementary education (χ² = 42.62, p < 0.001).

In terms of willingness to share HI, only 9.2% of patients selected ‘agree’ and 70.1% selected ‘disagree.’ In this aspect, education level played a key role (χ² = 35.11, p < 0.001).

In addition, patients’ attitudes towards HI differed significantly between those with long-term (mean = 6.27), medium-term (mean = 6.48), and early-stage diseases (mean = 6.52) (χ² = 24.31, p < 0.001). Patients with long-term courses of chronic disease showed more inactive attitudes compared to the other patients.

HI-related skills

The patients’ answers to the HI skills question are shown in Table 3. Older patients (χ² = 24.99, p < 0.001) and patients with long-term diseases (χ² = 15.07, p = 0.001) were more confident in assessing the quality of HI, as was the case with female (χ² = 10.50, p = 0.001) and highly educated patients (χ² = 18.77, p < 0.001).

Table 3.

Health information-related skills^a.

	Agree n (%)	Uncertain n (%)	Disagree n (%)
Evaluation (Cronbach’s α = 0.717)
1. I can evaluate the quality of health-related information.	517 (30.9%)	426 (25.5%)	728 (43.6%)
2. I can evaluate the reliability of health information sources.	202 (12.1%)	263 (15.7%)	1206 (72.2%)
3. When faced with more than one piece of health information, I can choose the best one for me.	447 (26.8%)	322 (19.2%)	902 (54%)
Expression and comprehension (Cronbach’s α = 0.756)
4. I know what kind of health information I need.	1112 (66.5%)	474 (28.4%)	85 (5.1%)
5. I can clearly express my health information needs to others.	859 (51.4%)	640 (38.3%)	172 (10.3%)
6. I can conclude and summarize the health information I acquire.	1029 (61.6%)	491 (29.4%)	151 (9%)
7. I can understand the drug purpose, usage, and dosage and contraindications in the drug instructions.	1337 (80%)	254 (15.2%)	80 (4.8%)
8. I can understand what the doctor says when I communicate with him.	902 (54%)	622 (37.2%)	147 (8.8%)
Seeking (Cronbach’s α = 0.789)
9. For me, it is easy to acquire health information from the internet.	420 (25.1%)	302 (18.1%)	949 (56.8%)
10. For me, it is easy to acquire health information from such traditional media as TV and radio.	1172 (70.2%)	413 (24.7%)	86 (5.1%)
11. For me, it is easy to acquire health information from printed materials such as books and magazines.	1130 (67.6%)	447 (26.8%)	94 (5.6%)
12. For me, it is easy to acquire health information from mobile technology such as mobile phones and tablets.	1114 (66.7%)	375 (22.4%)	182 (10.9%)

12-items, Cronbach’s α = 0.756.

For the survey item ‘evaluate the reliability of an information source’, most patients were not confident: 72.2% of the patients expressed that they did not know how to assess the quality of HI sources. However, the results were heterogeneous, depending on demographic characteristics and chronic disease conditions. For example, the seniors (χ² = 18.76, p < 0.001), undereducated (χ² = 31.96, p < 0.001), and long-term disease sufferers (χ² = 15.78, p < 0.001) were less confident.

Over half of the patients selected ‘agree’ for the five items concerning HI expression and comprehension. For item 4, young patients (χ² = 75.37, p < 0.001) and those in early disease stages (χ² = 16.44, p < 0.001) were more confident in ‘knowing what kind of information I need’. Similar results also applied to different demographic and disease factors for HI expression and comprehension abilities, as reflected in Items 5–8. In addition, young, highly educated patients and those in early disease stages or with high annual incomes were more confident in ‘expression of HI needs’, ‘conclusion and summary of HI’, ‘understanding drug instructions’, and ‘communication with doctors’.

Regarding seeking HI, only 25.1% of the patients showed that they had no difficulty acquiring information on the Internet, but the figures for the other three channels were >66%. The patients who outperformed were the young (χ² = 338.91, p < 0.001), the highly educated (χ² = 115.82, p < 0.001), and those with high incomes (χ² = 26.08, p < 0.001).

Relationships between attitudes and skills

Demographic characteristics (gender, age, education, annual household income, religion) and chronic disease status (number of chronic diseases, time post-diagnosis, and disease category) were the variables that were brought into multiple linear regression analyses to explore whether demographic characteristics and chronic disease conditions could predict the patients’ HI skills and their attitudes towards HI. As shown in Table 4, the female and highly educated patients cared more about health-related information than did the male and undereducated patients. Patients with high incomes were more confident in their HI skills. The chronic disease course negatively impacted the HI attitudes and seeking skills. Among all dependent variables, religious belief showed no predictive effect. Although the impact on attitudes and skills for patients with different diseases differed somewhat (p < 0.5), the low regression coefficient (β < 0.1) indicated that these effects were not significant. Finally, a two-way positive effect was found among the attitudes and three skills dimensions.

Table 4.

Results of the linear regression analysis for predicting attitude towards HI and HI-related skills.

		Attitude	Skills
			Evaluation	Expression and comprehension	Seeking
Demographic factors	Gender	0.15***	0.05	−0.01	−0.01
	Age	−0.08*	0.02	−0.29***	−0.30***
	Education	0.09**	0.16***	0.04	0.20***
	Annual household income	0.08**	0.08**	0.10***	0.08***
	Religion	−0.02	−0.01	−0.02	−0.03
Chronic disease status	Number of chronic diseases	−0.02	−0.02	−0.05*	−0.03
	Time post-diagnosis	−0.02	−0.01	0.05	−0.13***
	Disease category (other disease)
	Cardiovascular/ cerebrovascular disease	0.01	−0.09*	−0.03	−0.01
	Diabetes mellitus	0.07*	−0.06	0.02	−0.02
	Cancer	−0.01	0.01	−0.02	−0.07*
	Asthma/COPD	0.04	−0.05	−0.01	0.01
	Neurological disease	0.04	0.01	0.06*	0.01
	Digestive system disease	−0.01	−0.04	−0.05	−0.03
Relationship	Attitude	-	0.34***	0.29***	0.31***
	Skills	0.47***	–	–	–
	Evaluation	0.26***	–	–	–
	Expression & Comprehension	0.20***	–	–	–
	Seeking	0.19***	–	–	–

Standardized β is significant at *p < 0.05, **p < 0.01, ***p < 0.001.

HI: Health information

According to the results of the bivariate correlation analyses, the chronic disease patients’ attitudes towards HI moderately correlated with their HI skills (r = 0.47, p < 0.001). Furthermore, as the disease progressed, the correlation coefficients tended to decrease in the patients with early-stage (r = 0.49), medium-term (r = 0.45), and long-term (r = 0.44) diseases. To further examine the relationship between the patients’ attitudes and their HI skills, we divided their attitudes into three categories based on their scores (active, the top 25%; negative, the last 25%; and moderate, the middle 50%) and transformed this scoring system into a centesimal system. Our results showed that the patients with active attitudes towards HI had the highest scores in HI evaluation, expression and comprehension, and seeking: 50.4, 72, and 74, respectively. In contrast, the respondents with negative attitudes had the lowest scores for these dimensions: 28.4, 61.5, and 57.1, respectively. The patients with moderate attitudes were at medium levels in terms of the three dimensions. For every one grade the attitude ascended, the three HI skill dimensions increased by 11%, 5.3%, and 8.4%, respectively. Refer to Figure 1 for details.

Figure 1.

Relationship between attitudes towards HI and HI-related skills.

Confidence in HI sources

Patience confidence concerning the reliability of seven familiar HI sources is shown in Figure 2. Among the seven information sources, the three most trusted were doctors (93.2%), family members (74.7%), and friends (60.6%). Advertisements (67.2%), TV/broadcasts (7.66%), and the internet (7.12%) were the least trusted sources. The top three ‘general’ sources were the internet (59.6%), books/newspapers (47%), and TV/broadcasts (43.4%).

Figure 2.

Confidence of participants in the HI sources.

Discussion

Currently, no well-recognized, effective method to evaluate HI attitudes and skills has been established. Some studies have assessed patients’ HI knowledge and skills and analyzed their attitudes towards and cognition of certain illness information (19 –21). The questionnaire used in this study was developed based on the HI literacy concept proposed by the MLA and referred to the related terms in the HI literary self-assessment tools (22). In the tests for five coefficients of internal consistency, all Cronbach’s α were >0.7, indicating the relatively ideal internal consistency of the two scales. Furthermore, the three factor structures of HI skills generally met the MLA’s HI literacy requirements. Therefore, we can conclude that in general, the entire scale has good internal consistency and content validity.

For the nine items that assessed attitudes towards HI, 2.4%–27.7% of the patients selected ‘Uncertain’. For six of these items, more than 85% of patients selected ‘Agree’. These results indicate that the chronic disease patients had relatively explicit and active attitudes towards HI. In contrast, a large difference was found in the assessment of HI skills. The average scores for the 12 items ranged from 0.24 to 0.74 (full score, 1), indicating that the patients’ general skills were poor and differed greatly. This result was likely because information literacy skills are based on certain knowledge, experience and technology (23). As an important factor for cultivating and forming information literacy skills (24,25), education level was generally low (participant with a high education level only accounted for 10.3% of the total number of participants) in the present survey. This result was also proven by multiple linear regression analyses (see Table 4).

The impact of demographic characteristics on the HI attitudes and skills found in this study was similar to the findings from previous studies (24,26). The p value in the multiple linear regression analyses indicated that age, education level, and annual household income were three important factors influencing the participants’ attitudes towards HI and their HI-related skills. Responses to the item ‘willingness to study new method or skill for HI search’ differed from the previous studies (26,27), with the older patients indicating more willingness than the younger patients (χ² = 14.13, p = 0.001). In contrast, for the four items related to seeking HI, the older patients showed a lower level of confidence (χ² = 338.91, p < 0.001). One possible reason for this result is that compared with younger patients, the older patients had experienced longer disease courses (χ² = 975.73, p < 0.001) and, therefore, were eager to find health-related information when faced with health problems. However, this willingness was limited by the older patients’ lower information literacy levels (28,29), which resulted in their relatively poor capacity in actual information acquisition. Another interesting finding was that the patients in different disease stages showed opposing results in terms of the HI assessment ability. The patients with long-term disease courses had better HI quality assessment abilities than the early-stage patients, but the latter group was more confident in assessing the reliability of HI sources. This finding could attributed to the fact that the patients with long-term diseases were more experienced with HI assessment, but the early-stage patients were younger (r = 0.72, p < 0.001) and, therefore, were more skillful in media use and assessment (30).

In accordance with another study finding, the patients who paid more attention to HI had better HI skills in terms of assessment, expression and comprehension, or acquisition. Although we cannot determine whether the skill improvement resulted from active attitudes or vice versa, the positive correlation between attitudes and skills suggests that in chronic disease patients, cultivating an active attitude was beneficial in promoting their evaluation, expression and comprehension, and HI seeking abilities. Furthermore, as the diseases developed, this correlation tended to decline; the relationship between disease course and attitude towards HI (r = −0.11) showed a much lower correlation than the relationship between disease course and HI skills (r = −0.32), which suggests that training in HI-related skills should be the main aspect of health literacy promotion in patients suffering from long-term chronic diseases. Because age and education level were the major causes for the differences in patients’ attitudes towards HI (r = −0.14, 0.12) and their HI-related skills (r = −0.40, 0.31), special attention should be directed toward elderly and undereducated chronic disease patients.

With respect to respondents’ choices regarding trustworthiness of HI sources, one interesting finding was that although fewer than 55% of the participants had no difficulty in communicating with doctors, 93.2% of the patients chose their doctors as the most trustworthy HI source, indicating that a good doctor-patient relationship has become an important method of meeting the patients’ HI needs. In addition, that that that the Internet has become a major HI source (31). However, 30% of the patients in this study did not trust information obtained from the Internet. This result is quite different from that observed in developed countries (9,32,33); this difference may be attributable to individual education levels and information inquiry habits. By December 2012, Internet users accounted for 43% of the total population in China (34), but it will still take more time to change the information acquisition methods of most Chinese people. Finally, only 3.4% of the patients trusted information from advertisements, which may be associated with a series of inferior drugs (35) and deceitful medical advertisements (36) in China in recent years. This result indicates that the Chinese government should increase the supervision of medication advertisements to reduce the impact of advertising false information to the public.

The current study has some limitations. First, the survey in this study was performed in a large regional hospital, which could have resulted in selection bias. Second, the formation of individual attitudes and skills is complex. Although 21 items were introduced to assess chronic disease patients’ HI attitudes and skills, this strategy was still insufficient to guarantee that the assessment would reflect the patients’ attitudes and skills in a thorough manner. Third, this study did not provide an in-depth analysis of the social and cultural factors that could possibly influence patients’ HI attitudes and skills, such as race, religion, and social environment. Despite these limitations, the study is still valuable for explaining the relationship between attitudes towards HI and HI-related skills.

Conclusion and practice implications

The results of this study indicate that although chronic disease patients have relatively explicit and active attitudes towards HI, their general HI skills are inadequate. In addition, a positive relationship between the attitudes towards HI and HI-related skills was found in this study. These results suggest that training in HI-related skills should be the main aspect of health literacy promotion in patients who suffer from long-term chronic diseases, particularly for elderly and undereducated patients. However, cultivating an active attitude towards HI is significant for improving HI-related skills.

In addition, we found that doctors are still the most trusted sources for patients to obtain HI. This finding indicates that during communication with patients, doctors should pay attention to their ability to effectively communicate HI. Meanwhile, the Internet will become a major source for acquiring HI in the future. Therefore, improving patients’ HI assessment ability on the Internet has become a priority in promoting HI literacy. Finally, governments should strengthen the supervision and management of drug advertisements to build a reliable HI environment for chronic disease patients.

Footnotes

Acknowledgements

The author wishes to thank Prof. Xiao Shuiyuan (Central South University, China), for his help in study design, and Dr. Raimo Niemelä (University of Oulu, Finland) for his assistance in assessment tool compilation. We thank American Journal Experts (AJE) for English language editing.

Conflicts of interest

There are no conflicts of interest.

Funding

This study was supported by the Key Science and Technology Project of the Science and Technology Department of Hunan province China (grant number 2012SK2004), the Fundamental Research Funds for the Central Universities of Central South University (grant number 2013zzts075), and Chinese National Planning Office of Philosophy and Social Sciences (grant number 13BTQ044).

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